HRT route to medical madness

"How would you treat a menopausal patient complaining of severe hot flushes, insomnia, inability to concentrate at the office, wanting to kick her husband and suffering from painful sexual intercourse?"

I posed this question to a number of doctors at a recent medical meeting. I was shocked to hear that many would prescribe a variety of anti-depressant medicines such as Prozac and Effexor. It's the perfect example of how the results of a statistical study can cause panic, and result in poor medical advice.

In 2002, a U.S study called The Women's Health Initiative reported that postmenopausal women who took hormone replacement therapy (HRT) longer than four years had an increased risk of breast cancer, heart attack and stroke. These headlines left women with the impression that if they took HRT they would get cancer. Sales of female hormones plummeted.

Unfortunately, it was not stressed that the risk of these problems was extremely small. For instance, there were eight more cases of breast cancer and seven more cardiovascular problems for every 10,000 women per year of use.

I wrote at that time that estrogen had been used for 60 years by millions of women. Good sense should tell researchers that if estrogen were a major risk factor for breast cancer, there would be a raging epidemic of this disease by this time.

I also stressed that everyone should look on large statistical studies with considerable skepticism. As one of Harvard's most famous professors once remarked, "If you have to prove something by statistics, it's usually wrong."

However, let's assume the figures were right. In that case, it seemed reasonable that women should discontinue HRT if it was possible for them to do so. But life is rarely that simple.

Now we know that one in four women who stop HRT are paying a price. They return to their doctor saying, "I can't stand being off it any longer. I'm going to lose my job. I can't sleep. I have embarrassing sweats, and sex causes too much pain."

ESTROGEN PATCH

For these women, there is only one sure cure, HRT. But what I prescribe for such patients depends on the symptoms.

For instance, if they have had a hysterectomy, all they need is a low dose of oral estrogen or the estrogen patch. For those who have not had a hysterectomy, a combination of both estrogen and progestin is preferable. This combination helps to prevent an increase in the thickness of the lining of the uterus. And after a few days of treatment these patients no longer want to kick the cat.

But what about women who only suffer from painful sexual intercourse due to a thinning of the vaginal lining (senile vaginitis) caused by a lack of estrogen? The nightly insertion of Vagifem, a vaginal estrogen tablet, for 14 nights, quickly restores the lining to its normal thickness. Then, to prevent recurrence, it can be used once or twice a week. No report in the world has ever implicated the use of vaginal estrogen as a cause of malignancy.

The use of hormones in these situations makes much more sense than prescribing anti-depressant drugs. First of all, anti-depressant drugs don't cure menopausal symptoms or have any effect on senile vaginitis. Moreover, these drugs are not like taking M&M candies. They can cause a list of complications as long as your arm. I never cease to be amazed at the nonchalant way women, and men, swallow anti-depressant medications.

The fact that doctors prescribe powerful anti-depressant drugs to treat menopausal symptoms shows how far we've strayed from common sense. In this life, there's no free lunch with any drug. It's simply a matter of weighing the risk of one medication against another. And in this case, it's a "no brainer" that the minimal risk of HRT is far less than the long term risk of anti-depressant drugs.

The more I see of today's society and its demands on medicine, the more I'm convinced that Samuel Beckett was right when he suggested, "We are all born mad and some of us remain so!"